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Concept: Nerve block

152

The use of peripheral nerve blocks for anesthesia and postoperative analgesia has increased significantly in recent years. Adjuvants are frequently added to local anesthetics to prolong analgesia following peripheral nerve blockade. Numerous randomized controlled trials and meta-analyses have examined the pros and cons of the use of various individual adjuvants.

Concepts: Randomized controlled trial, Anesthesia, Local anesthesia, Morphine, Ketamine, Local anesthetic, Anesthetic, Nerve block

30

Currently available local anesthetics approved for single-injection peripheral nerve blocks have a maximum duration of <24 hours. A liposomal bupivacaine formulation (EXPAREL, Pacira Pharmaceuticals, Inc., San Diego, CA), releasing bupivacaine over 96 hours, recently gained Food and Drug Administration approval exclusively for wound infiltration but not peripheral nerve blocks.

Concepts: Pharmacology, Anesthesia, Local anesthesia, Local anesthetic, Peripheral nervous system, Block, Nerve block

28

Femoral continuous peripheral nerve blocks (CPNBs) provide effective analgesia after TKA but have been associated with quadriceps weakness and delayed ambulation. A promising alternative is adductor canal CPNB that delivers a primarily sensory blockade; however, the differential effects of these two techniques on functional outcomes after TKA are not well established.

Concepts: Femoral vein, Peripheral nervous system, Femoral nerve, Saphenous nerve, Nerve block, Adductor canal

27

The therapeutic rationale, clinical effectiveness, and potential adverse effects of medications used in combination with local anesthetics for peripheral nerve block therapy are reviewed.

Concepts: Pharmacology, Medicine, Effectiveness, Anesthesia, Local anesthetic, Nerve block

27

BACKGROUND: Historically, the anterolateral interscalene block-deposition of local anesthetic adjacent to the brachial plexus roots/trunks-has been used for surgical procedures involving the shoulder. The resulting block frequently failed to provide surgical anesthesia of the hand and forearm, even though the brachial plexus at this level included all of the axons of the upper-extremity terminal nerves. However, it remains unknown whether deposition of local anesthetic adjacent to the seventh cervical root or inferior trunk results in anesthesia of the hand and forearm. METHODS: Using ultrasound guidance and a needle-in-plane posterior approach, a Tuohy needle was positioned with the tip located between the deepest and next-deepest visualized brachial plexus root/trunk, followed by injection of mepivacaine (1.5%). Grip strength and the tolerance to cutaneous electrical current in 5 terminal nerve distributions were measured at baseline and then every 5 minutes following injection for a total of 30 minutes. The primary end point was the proportion of cases in which the interscalene nerve block resulted in a decrease in grip strength of at least 90% and hand and forearm anesthesia (tolerance to >50 mA of current in all 5 terminal nerve distributions) within 30 minutes. The primary hypothesis was that a single-injection interscalene brachial plexus block produces a similar rate of anesthesia of the hand and forearm to the published success rate of 95% for other brachial plexus block approaches. RESULTS: Of 55 subjects with blocks placed per protocol, all had a successful block of the shoulder as defined by inability to abduct at the shoulder joint. Thirty-three subjects had measurements at 30 minutes following local anesthetic deposition, and only 5 (15%) of these subjects had a surgical block of the hand and forearm (P < 0.0001; 95% confidence interval, 6%-33%). We therefore reject the hypothesis that the interscalene block as performed in this study provides equivalent anesthesia to the hand and forearm compared with other brachial plexus block techniques. Block failures of the hand and forearm were due to inadequate cutaneous anesthesia of the ulnar (n = 27; 82%), median (n = 26; 78%), or radial (n = 22; 67%) distributions; the medial forearm (n = 25; 76%); and/or the lateral forearm (n = 14; 42%). Failure to achieve at least a 90% reduction in grip strength occurred in 16 subjects (48%). CONCLUSIONS: This study did not find evidence to support the hypothesis that local anesthetic injected adjacent to the deepest brachial plexus roots/trunks reliably results in surgical anesthesia of the hand and forearm.

Concepts: Surgery, Anesthesia, Local anesthesia, Forearm, Ulnar nerve, Local anesthetic, Brachial plexus, Nerve block

7

Much controversy remains on the role of anesthesia technique and peripheral nerve blocks (PNBs) in inpatient falls (IFs) after orthopedic procedures. The aim of the study is to characterize cases of IFs, identify risk factors, and study the role of PNB and anesthesia technique in IF risk in total knee arthroplasty patients.

Concepts: Hip replacement, Orthopedic surgery, Joint replacement, Knee replacement, Peripheral nervous system, Nerve block

3

BACKGROUND:A well-known complication of peripheral nerve block is peripheral nerve injury, whether from the needle or toxicity of the medication used. In this study, we sought to determine the extent of damage that results from intrafascicular injection of various commonly used local anesthetics (LAs).METHODS:Sixteen Lewis rats received an intrafascicular injection of saline (control) or 1 of 3 LAs (bupivacaine, lidocaine, or ropivacaine) into the sciatic nerve (n = 4). At a 2-week end point, the sciatic nerves were harvested for histomorphometric and electron microscopic analysis.RESULTS:Animals that received intrafascicular LA injections showed increased severity of injury as compared with control. In particular, there was a significant loss of large-diameter fibers as indicated by decreased counts (P < 0.01 for all LAs) and area (P < 0.01 for all LAs) of remaining fibers in severely injured versus noninjured areas of the nerve. There was a layering of severity of injury with most severely injured areas closest to and noninjured areas furthest from the injection site. Bupivacaine caused more damage to large fibers than the other 2 LAs. In all groups, fascicular transection injury from the needle was observed. Electron microscopy confirmed nerve injury.CONCLUSIONS:Frequently used LAs at traditional concentrations are toxic to and can injure the peripheral nerve. Any combination of motor and/or sensory sequelae may result due to the varying fascicular topography of a nerve.

Concepts: Anesthesia, Local anesthesia, Injury, Epidural, Local anesthetic, Damage, Anesthetic, Nerve block

2

Despite the benefits of continuous peripheral nerve blocks, catheter dislodgment remains a major problem, especially in the ambulatory setting. However, catheter dressing techniques to prevent such dislodgment have not been studied rigorously. We designed this simulation study to test the strength of two commercially available catheter dressings.

Concepts: Cultural studies, Peripheral nervous system, Block, Nerve block, Blocking, Ambulatory care

1

Peripheral nerve blocks are popular as a mode of anaesthesia for limb surgery and their beneficial effects are well documented in elective surgery. However, concerns have been raised about potential rebound pain outweighing the benefits in acute ankle fracture surgery. Furthermore, pain scores and morphine consumption do not provide a full picture, as pain is subjective. To evaluate the clinical usefulness of peripheral nerve blocks, we explored patients' expectations and experiences by means of semi-structured interviews analysed with systematic text condensation. We obtained ethical approval and informed consent and sampled purposively among adult patients scheduled for ankle surgery with nerve blocks as the primary mode of anaesthesia. Patients were interviewed within 48 h postoperatively. Data saturation was reached after 13 interviews. We found that, despite pre-emptive ibuprofen and paracetamol, some patients did experience excruciating rebound pain for up to 2 h, although most had little or no pain. The patients had doubts about what to do when the block wore off, which led to a risk of unnecessary pain levels or morphine overuse. Patients had difficulty understanding the effect and course of the nerve blocks. They had misunderstandings regarding the blocks' effect on sensation, resulting in fear of feeling pain during surgery and of permanent nerve damage after surgery. However, patients valued the mental alertness, ability to ambulate and efficient pain relief provided by the blocks. We recommend that patients be given thorough and repeated information as we feel this is crucial in preventing undesirable responses from patients, and is likely to increase the overall clinical usefulness of nerve blocks in acute limb surgery.

Concepts: Clinical trial, Informed consent, Surgery, Anesthesia, Opioid, Human leg, Local anesthetic, Nerve block

1

Ultrasound guidance is becoming standard practice for needle-based interventions in anaesthetic practice, such as vascular access and peripheral nerve blocks. However, difficulties in aligning the needle and the transducer can lead to incorrect identification of the needle tip, possibly damaging structures not visible on the ultrasound screen. Additional techniques specifically developed to aid alignment of needle and probe or identification of the needle tip are now available. In this scoping review, advantages and limitations of the following categories of those solutions are presented: needle guides; alterations to needle or needle tip; three- and four-dimensional ultrasound; magnetism, electromagnetic or GPS systems; optical tracking; augmented (virtual) reality; robotic assistance; and automated (computerised) needle detection. Most evidence originates from phantom studies, case reports and series, with few randomised clinical trials. Improved first-pass success and reduced performance time are the most frequently cited benefits, whereas the need for additional and often expensive hardware is the greatest limitation to widespread adoption. Novice ultrasound users seem to benefit most and great potential lies in education. Future research should focus on reporting relevant clinical parameters to learn which technique will benefit patients most in terms of success and safety.

Concepts: Better, Clinical trial, Improve, Following, Peripheral nervous system, Nerve block, Limitations, Statute of limitations